Clinical guidelines focus on statins for dyslipidaemia management for prevention of cardiovascular disease. It is clear, however, that there remains an unacceptably high residual risk of further events among patients who achieve target low-density lipoprotein (LDL) cholesterol levels. Low high-density lipoprotein (HDL) cholesterol levels, an independent predictive factor, is likely to be an important contributor to this excess risk, and is also common among dyslipidaemic patients. The ARBITER 2 study (ARterial Biology for the Investigation of the Treatment Effects of Reducing cholesterol) showed that raising HDL cholesterol with prolonged-release (PR) nicotinic acid in addition to lowering LDL cholesterol with a statin slows progression of atherosclerosis, and would therefore be expected to improve cardiovascular risk reduction in this setting. This economic analysis evaluated the cost-effectiveness of this strategy using computer simulation economic modelling incorporating two decision analytic sub-models.
In the first sub-model, a cohort of 2,000 patients was generated using baseline characteristics and statin effect from the Heart Protection Study. Treatment effects observed with PR nicotinic acid (1,000 mg/day) in the ARBITER 2 study were then applied. The second model evaluated long-term clinical and economic outcomes using Framingham risk estimates. Direct medical costs were accounted from a National Health Service (NHS) perspective and discounted by 3.5%. In the UK setting, the addition of PR nicotinic acid to statin therapy resulted in long-term reduction in CHD events and increased life expectancy in patients who had achieved target LDL cholesterol levels but had persistently low HDL cholesterol, and this was achieved at a cost well within the threshold (< £30,000 per life years gained) considered good value for money in the UK. This strategy was highly cost-effective in patients with diabetes. Thus, adding PR nicotinic acid to statin therapy in these patients is both clinically and cost-effective and could be recommended for routine use in this setting in the UK.